Healthcare Provider Details

I. General information

NPI: 1801843974
Provider Name (Legal Business Name): MIDWEST EMERGENCY DEPARTMENT SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S 3RD ST
BELLEVILLE IL
62220-1915
US

IV. Provider business mailing address

PO BOX 8882
FORT WORTH TX
76124-0882
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-2120
  • Fax:
Mailing address:
  • Phone: 817-451-4208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM W CRUZEN
Title or Position: PRESIDENT
Credential: DO
Phone: 618-624-3368